Skills of Motivational Interviewing

Motivational Interviewing Skills

Motivational interviewing contains skills that are found in many treatment approaches that focus on building trust and rapport with a patient, as well as expressing empathy and exploring the patient’s concerns and barriers to therapy/treatment. As part of the motivational interviewing approach, there are 5 core skills that are often identified.^{20, 21}

They include:

1. Expressing empathy
2. Developing discrepancy
3. Avoiding arguing
4. Rolling with patient resistance
5. Supporting self-efficacy

 Expressing Empathy

An important component of motivational interviewing is showing empathy. Empathy, like all skills, however, needs to be developed. It involves acknowledging your patient’s current experience and situation, and accepting their viewpoint/experience/personal ambivalence without judgement. With empathy, comes acceptance. When there is acceptance, and the patient feels heard and validated, they are more open to change.^{20, 21}

Example statements:

• “I acknowledge how frustrating this is for you, not seeing the progress that you wish to see”
• “Making that decision must have been very difficult for you”
• “Many people report feeling like you do. They want to address their weight but find following the meal plan very difficult”
• “I appreciate how difficult this is for you and the significant changes that you have had to make”
• “That’s not unusual, I have worked with many people who have made many previous attempts to address their weight, just like you…”

Developing Discrepancy

One of the core principles of motivational interviewing focuses on intentionally eliciting change by helping the patient to explore and resolve their ambivalence.^{20, 21} This is achieved by creating a discrepancy between the client’s current situation and the desired one – both viewpoints (the pros and cons) are discussed with the patient. This is achieved with the use of the decisional balance tool. You can see an example of the decisional balance tool below.

When working through the decisional balance tool, it is important to start on a positive note as this helps to reduce patient resistance. The aim is to also end on a positive note by encouraging the patient to reflect on what their life could look like if they were to make some positive change.

As highlighted in the table, we firstly begin by asking the patient what is going well for them in their current situation. We acknowledge a few key points they’ve raised by reflecting this back to our patients. We then flip the coin by asking them to reflect on some of the not-so-good things about their current situation and/or behaviour.

The third part of the decisional balance tool is to then explore the patient’s concerns and what gets in the way of them making some change. We ask them about their current challenges and hurdles; what would make it difficult for them to move forward. We reflect this information back to the patient, but we also ‘park it’. We want to come back to this information at a later stage when we’re working on possible action plans with our patients and reflecting on what might get in the way of positive change.

The fourth and final part of the decisional balance tool, is to ask the patient what the benefits might be for them if they were to make some change. We explore this further by asking them how they would feel about experiencing positive change, and how they would like to proceed moving forward.

Read this example of the decisional balance tool in action. And remember, at each stage in the decisional balance tool, you can reflect back and summarise on what the patient may have told you.

_{Adapted from the Decisional Balance Tool training created by Health & Wellbeing Training Consultants 2020}

By utilising this approach, the patient is given the opportunity to explore both the pros and cons of their current situation and/or current behaviour, i.e. the good things about their current situation/behaviour, and the not so good things, or what is going well for them right now and what is not going so well.

This approach allows the patient to express and present their own arguments for and against change; it helps the patient to recognise the differences between their present behaviour and/or situation and the desired change.

The aim is to help them notice the discrepancies, to emphasise them, and in particular to create and increase their discomfort with their current behaviour and/or situation. Discomfort is what encourages individuals to start thinking about change, and if enough of it has been created, to act.

Patients are more motivated to change when they see what they’re currently doing will not lead them to a future goal, i.e. improved health and wellbeing. This process helps to encourage, empower, move, and motivate the patient towards positive change.^{20, 21, 23}

Avoiding Arguing

This third key skill of motivational interviewing is an obvious one. Confronting patients about their current behaviour/situation and/or the decisions they’re making, do not enhance the behaviour change process but creates the opposite effect instead – it enhances the patient’s defence mechanism.

Confronting your patients can lead them to feel unheard and undervalued, and as a result, this can lead to client anger, denial and resistance. The clinician’s aim is to minimise this response as much as possible.

Motivational interviewing is also based on the patient being the expert and knowing what is best for them. So, in the spirit of collaboration, the patient and the clinician work together. The clinician attempts to accurately understand their patient’s perspective with empathy and without judgement, and in turn, the patient feels safe enough to share their ideas, concerns and expectations^{20, 21, 23}

 Rolling With Resistance

The fourth skill of motivational interviewing is rolling with resistance^{20, 21}. This means that we work with what the patient presents and do not directly battle against their resistance. Arguments are avoided and instead, the clinician side steps or shifts focus to reduce the patient’s resistance. At the same time, the clinician continues to connect with their patient by showing empathy and by acknowledging the patient’s viewpoints and concerns.

We do not argue, dispute, or contradict what the patient is saying when we’re rolling with resistance. As an alternative, we build on this momentum by reframing the patient’s statement and inviting them to reflect on a new perspective. By doing so, we give new meaning to what the patient presents as their argument for staying the same. For example:

“Perhaps this new way of preparing your meals is all too much at the moment.”
“Maybe you’re just not ready to address your weight right now and that’s okay.”
“Even during this difficult time and all the challenges that you are experiencing, you’re still very determined. Your strong desire to address your weight (despite all your challenges) indicates how very important this is to you.”

The crucial part of rolling with resistance is that the new perspectives that you offer are invited, and not imposed on the patient.

 Supporting Self-efficacy

The fifth skill of motivational interviewing is supporting self-efficacy.^{20, 21} This skill focuses on building the patient’s confidence and skill and their ability to make a positive change.

This is based on the premise that change is possible and achievable, which gives hope to the patient that with the right information and support, they too can make a change. Like self-fulfilling prophecies, your patient needs to believe that they can change. Their belief is an important motivator and will propel them to take action. This belief can also help them reflect on what they will do or can do, to cope with high-risk or difficult situations.